New recommendations on mammography screening for breast cancer came out yesterday from the United States Preventative Services Task Force, a complete reversal of their previous recommendations last made in 2002. The Task Force recommends no longer doing routine mammography screening for breast cancer in women between the ages of 40 and 50 as well as reducing the frequency of screening for women aged 50-74 to once every two years, and not teaching women breast self exams. This was reported yesterday in the New York Times by reporter Gina Kolata. While the article is pretty thorough, it misses some of the details underlying the controversy.
During lunch I took the time to read through the recommendation, published today in the Annals of Internal Medicine, to see for myself what all the hubbub is about. What I read was disturbing. The report begins by stating “There is convincing evidence that screening with film mammography reduces breast cancer mortality,” although the greater reduction is seen for women aged 50-74, there is also reduction also seen for women between 40 and 50 years as well. This to me seems like a benefit to early screening, not a reason to stop.
Well, maybe the small number of women who can be helped by early screening between ages 40-50, about 1 in 1904 people, is outweighed by the risks and harmful effects of screening? That seems like it might be a good reason to not recommend early screening. The report discusses the risks for people who might show up as false positives during a film mammography. Specifically it cites psychological harm, unnecessary follow-up testing and biopsies, and “inconvenience.” Really?! Inconvenience? Is the task force seriously citing inconvenience for some people as a reason not to save the life of 1 person in 1904? They go on further to say that these risks are only “moderate”, “transient”, and “not a barrier to screening.” So again, why change the screening recommendation?
I kept on reading, searching for good sound cause for changing the recommendation. Instead I find that there is only “moderate certainty that the net benefit [of screening] is small,” for women between the ages of 40-50. So the Task Force is basing their opinion, a complete reversal from a few years ago, on something they only feel luke-warm about? Something that they only have “moderate certainty” about?
The Task Force also bases its opinion on the probable “overdiagnosis”, and subsequent “overtreatment” of breast cancer. What this means is that not all breast cancers detected and treated would have been lethal or even harmful if they had not been treated. That’s nice and all, but there have been no studies showing the rates of “overdiagnosis” of breast cancer, so this opinion is based entirely on assumption. They recommend instead, screening the cancer to determine whether it should be treated or may be ok left untreated. Unfortunately, this technology does not exist for clinical use yet. Many people are working on it, but the details still need to be hashed out. So instead then is the task force saying that since we can’t prevent “overtreatment” once a breast cancer is detected, it is best not to detect the cancer in the first place?
So what about women who may be predisposed to breast cancer? The report states that the recommendation applies only to women without an increased risk. But they define increased risk as “known underlying genetic mutation or a history of chest radiation.” Um, what about unknown genetic causes? It’s known that having family members with cancer increases the risk of getting cancer yourself – but genetics isn’t advanced enough to have identified all the specific mutations that cause this!
Also, just to clarify, as this hasn’t really been pointed out in any of the reporting I’ve seen. This recommendation applies only to film mammography. There are two types of mammography currently in use, film and digital. Film is less expensive than digital but many doctors are switching over to digital mammography which increases detection in younger age groups (the group of concern here) and is better for women with dense breast tissue. The Task Force doesn’t really have any recommendations for digital mammography – not very useful as there is a trend towards going digital.
So why was the recommendation changed? I’m a bit flummoxed. Today, NPR’s Here and Now produced by WBUR Boston also covered this issue and talked with Dr. Tim Johnson, the Medical Editor for ABC News. He suggests there may be political motivations with the health care debate underway. Dr. Johnson, as well as the NY Times article, brings up the point that this panel’s recommendations are followed by insurance providers such as the government provided Medicaid. This leads to question of whether Medicaid will continue to pay for mammograms for women under 50. And other insurance companies may follow the government’s lead on this.
Just to point out, this recommendation is also at odds with other profession organizations including the American Cancer Society which stands by its recommendation that women should begin getting mammograms at age 40.
Good luck to all those women between the ages of 40-50 now thoroughly confused about whether or not to get a mammogram.